Book Review – Better: A surgeon’s notes on performance

Better: a Surgeon’s notes on performance is written by General Surgeon and staff writer for The New Yorker Dr. Atul Gawande. Better was released in 2007 and precedes Gawande’s 2009 NYT best seller, The Checklist Manifesto.

I thank Steve Whitehead of The EMT Spot for including a link to an @ Google Talk video of Atul in his March newsletter. I will mimic Steve in encouraging you to watch the video, it is well worth the 58 minutes.

When it comes to speakers or writers I will generally listen to anybody that is both well spoken and provides references. This combination is more rare than one would imagine. Atul exhibits both of these traits in spades. He writes in a clear and very organized fashion.

The book first describes a few dichotomies that exist within modern medicine. Atul, with the use of relevant and interesting anecdotes, places you emotionally on one side of a debate and then swiftly carries you to the other. One example is a look at malpractice law in the US. He begins by describing a legal case he witnessed and the feelings of the, apparently unjustly, accused well-meaning physician. As a prehospital care provider my blood boiled listening to the recount of how the physician was questioned on tiny insignificant details and suffered blatant attempts at character assassination. Atul then describes the son of a prominent physician who developed advanced thoracic cancer. In determining how a cancerous mass so large went unnoticed it was discovered radiologists had noticed the mass in unrelated procedures. These reports slipped through bureaucratic cracks though and nothing was done. As angry as I was at the patient before my emotions now vacillated to decry the medical establishment for such an error of ineptitude.

And then Atul does what he does best. The strength of Atul’s writing is not in his ability to draw emotional responses but in his critical thinking skills. You realize in many of the examples that the dichotomy has no simple answer. In many intellectual debates there is no clear “bad guy” to calibrate our moral compasses with. The book concludes with a look at the bell curve in medicine. He examines the mean life span of patients with cystic fibrosis. After visiting a large well established centre performing around the mean Atul then visits the top end of the bell curve. A clinic whose patients can expect over 60 years of healthy life.

Atul’s overall opinion is that contemporary medicine focuses too much on scientific and technological breakthroughs. He asserts, with of course references and examples, that many problems our patients present with today can be treated with existing technology. When we fail to help a patient it may very well be because a protocol is not currently allowed in our jurisdiction or the equipment is too difficult to procure. He terms these errors of ineptitude. The book concludes with five small suggestions each and every one of us can implement today to improve patient care.